This blog is totally independent, unpaid and has only three major objectives.
The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide.
The second is to provide commentary on e-Health in Australia and to foster improvement where I can.
The third is to encourage discussion of the matters raised in the blog so hopefully readers can get a balanced view of what is really happening and what successes are being achieved.

Wednesday, April 29, 2015

Surely This Is A Problem That Can Easily Solved By Proven E-Health Technology. All It Needs Is Will, Proper Sponsorship and Governance.

Julia Medew Health Editor

Victorians are dying because of inadequate IT systems for hospital staff to communicate crucial information about their care to GPs, doctors say – with many still relying on faxes.

Despite more than $1 billion being spent on healthcare technology over the past decade, the Victorian branch of the Australian Medical Association says thousands of patients are being shunted around between doctors every day without a standardised system to efficiently transmit their personal information.

The chairman of AMA Victoria's section of general practice, Dr Michael Levick, said this "ad hoc" approach to communicating patients' diagnoses, test results and treatments was so dangerous, he knew of patients who had died as a result.

In one recent case, he said a patient bled to death after being discharged from hospital because they were on the blood thinning drug warfarin and did not realise they had to get their GP to check their dose in the following days.

"They did turn up to their GP but their GP had no idea they were on warfarin because there was no communication and their blood thinned too much. The patient died," he said. "That can easily happen."

Dr Levick said while most GPs kept safe electronic records of their patients' history and received secure email messages from pathology and diagnostic imaging providers, there was a major breakdown between GP clinics and hospitals.

He said when patients were discharged from hospitals, their GPs could receive anything from a phone call, fax, email or printed letter explaining their diagnoses and treatments, and what needed to happen next. Sometimes, though, they received nothing at all.

"There is no reliable form of communication that everyone uses … so no one can rely on anything that comes out as being the full truth," he said. "In terms of patient safety and inefficiency, it is a huge issue."

Doctors in Victoria say patients are dying due to inadequate technology and poor communication between hospitals and local GPs, and have called for $50 million to help fix the problem.

Privacy laws mean emails about patients medical history have to be encrypted, but only a few hospitals have the technology to do that.

The chairman of the Australian Medical Association Victoria's section of general practice, Dr Michael Levick, said vital patient information was instead being passed on via written notes or by fax.

He said that meant updates about major changes to patient treatment while they were in hospital were often delayed or even missed completely.

Dr Levick said communication methods between GPs and hospitals had not changed much in the past two decades.

"It is either a handwritten or typed piece of paper that comes with the patient, sometimes fax, sometimes there's a phone call from the doctor at the hospital to the general practitioner," Dr Levick said.

"Sometimes there's a letter in the mail that comes eventually, or sometimes there's absolutely nothing.

"Some hospitals do have the ability to send secure messages, which is like an email which arrives at the doctor's surgery immediately, but that is few and far between.

"This leads to patients not getting adequately treated or monitored when they come out of hospital."

Dr Levick said in one instance a patient died because their GP was not told about their blood thinning medication, which required daily monitoring.

What is missing here are the management and governance systems that makes sure the information flows between hospitals and service providers and a little money to get things organised.

Already most GPs can receive secure clinical messages and already most service providers can send secure clinical messages.

It’s the will, governance and management that is missing!

Sadly to get to where we need to be - here and in the rest of the country - we need Government(s) to be acting as enablers and supporters and organisations, like the AMA to push! With that happening this is an easily soluble problem that should have been fixed ages ago!

I believe that your statement: "Already most GPs can receive secure clinical messages and already most service providers can send secure clinical messages" is not correct.

If 'service providers' includes public and private hospitals, medical specialists in private practice and other health professionals and organisations, in my experience most of them have not yet equipped themselves with any secure message (SMD) system such as Argus.

Amongst GPs, many practices that have installed one more more SMD systems (which is still necessary because of lack of interoperability between these systems) use them only to receive messages and do not use them to send messages.

Many hospitals, medical specialists and other health professionals are adopting a quick and dirty approach by using standard unencrypted email to communicate with and about patients. Apart from the serious privacy issues with this, the messages can not be filed automatically into the patient's electronic clinical record.

Small cost and some will ..... this will fix nothing. There has been more than enough money and plenty of exposure and discussion around SMD not to mention a lot of work by many 'experts'. The end result is still lots of holes.

So ask yourselves why is this so?

What are the obstacles to progress? Is this a job for many small vendors? Is this a job for Telstra? Why haven't NEHTA and DoH made progress? If Argus is so good (now Testra owned) why has it not been more widely embraced? What is the viable business model underpinning SMD? What strategies are required to secure market traction with a compelling SMD system? That should do for starters. Answer those questions and then decide if small cost and some will is sufficient.

Lack of interoperability between the SMD systems. I understand that some of the reason for this is now a commercial issue, rather than a technical one, with the SMD vendors not yet having reached agreement about in what proportion the sending and receiving SMD systems will pay to troubleshoot and fix problems when messages are not delivered. I suggest that David More seeks comment on this from the SMD vendors.

"Is this a job for many small vendors?"

It could be, if their products are interoperable.

"Is this a job for Telstra?"

Telstra thinks so, it seems.

"Why haven't NEHTA and DoH made progress?"

How long have you got to hear the answers?

"If Argus is so good (now Testra owned) why has it not been more widely embraced?"

I didn't say that it was so good. It, like its competitors, is trying to fill a need by providing communication between users of clinical systems, for whioh there are still no standards in Australia. This lack of standards makes the task difficult.

"What is the viable business model underpinning SMD?"

The use of SMD systems should be paid for by government in the interests of improving the safety, quality and efficiency of care. This would cost much less than has been spent in recent years on projects that are not working.

"What strategies are required to secure market traction with a compelling SMD system?"

Interoperability, and there does not need to be only one "compelling" SMD system.

Oliver, you and I have been debating this for more than a decade. I too am surprised we havent moved further faster in Au.

In most of Au an average general practice communicates electronically with about 5 entities including labs. In the Easternmost state (NZ)the average practice connects to 70 other parties. All hospital referrals are electronic in most regions. All NZ discharge summaries are.

Its time we took a serious look at why this relatively straight forward technology is not being embraced in Au.Space does not permit that to happen here.

Tom, New Zealand is clearly way ahead of Australia on this, and has been so for ages. I think that being a simple small (and beautiful) country has some great advantages when national schemes and programs are being planned and implmented.

Interoperable messaging relies on compliant messages and compliant receivers to allow the smooth flow of messages. We don't have that now, you can't send a compliant message and have it just work. There is a lot of hand holding going on and not a lot of investment in standards compliance at the low level.

This is the fundamental block in the free exchange of information, its a lack of quality in receivers that is the first hurdle to overcome. When that is done we can try and encourage senders to produce high quality messages. If that worked reliably then messaging would become a commodity - but we are a long way from that now.

Oliver, while shooting the messenger is always good sport I suggest you ask the people you want to communicate with the send you an example 100% compliant HL7 V2 message by email and (a) see if they can do that the (b) see if that message works reliably in your system. You will then find that the problems start at the step before messaging becomes useful - the quality (and even availability) of the underlying messages and presentation and handling of those messages by receiving systems.

Its time we focused on underpinning the foundations before trying to add another story to this rickety building.

Some years ago, during one of our recurring attempts to get eHealth going in our particular sector, I pointed out to the NEHTian then in charge of our area (now long since moved on) that practices would not invest in HW/SW without knowing that they were investing in interoperable products with a long-term future - ie ones backed by agreed and mandated standards - and asked what would be done about implementing such. The response was along the lines of : 'Oh no, we couldn't get involved in that - that's for the industry to do'

Let's face it - Health Ministers Tony Abbot, Nicola Roxon and Tanya Plibersek have all been conned to the eyeballs by NEHTA and the Department in regards to eHealth. Hopefully Sussan Ley will seek advice from some less public eHealth experts who have the wisdom, insight and expertise to make change(s)happen from behind the scenes. Her non Departmental staff know how to access these people free of Departmental interference. She is the first health minister this country has had for a very long time who may be able to redirect Gov't eHealth initiatives if she can get access to the right advice.

Oliver,Thanks for compliments about NZ, it'd be be great if you looked us up when you are over, it is a great place.

I don't agree that scale is the key issue. Government needs to lead and paint a broad picture of the outcome it wants, if necessary providing incentives (in my view incentives are dangerous things). There is money enough in the health sector, it is soften misused.

Key point is - you (GOVT) need to align the economic drivers of those who will benefit from change and encourage them to get on with it.

In many senses the story of Australia is one of 'hurry up and wait' while we know all do it for you. Wrong approach.

Secondly, we need to have the hard conversations about shared records, are they getting there? will they ever get there? is there a better alternative?

K,Oliver, Lets get down to it, in order to make change in the health sector you have to make CHANGE. Governments don't seem to be capable of it.

There is a saying "to make an omlette you have to break some eggs"

eHealth is aseries of interventions in a very costly, well funded healthcare ecosystem in which most parties do pretty nicely thank-you.

Where do the much vaunted eHealth efficiencies come from? they come from costs savings of course and where do cost savings come from? They come from disinter-mediation, disruptive innovations etc, etc.There are winners and losers.

It is a battleground and not one governments should be anywhere near.

Why would you get everyone in the room, to hold hands?, have a seance? disruptive innovation and industry change doesn't work that way.

Identify parties that can make disruptive change, be clear and transparent about the objectives are (role of govt) and stand well back - No other formula will work. Believe me.

Its quite wrong to say its not happening in Australia. Last month my practice sent out 1353 reports to 143 separate practices and they are either clinical messages or lab reports that we forwarded without involving the lab directly.

On the Sunshine Coast we are delivering around 200,000 messages a month, and the vast majority of those are clinical. Compare that to 500 views of the PCEHR. The technology to do it exists today and I would have to ask Oliver why he is not sending messages?

It does take time to build the clinical traffic, but in the places where Medical-Objects has been the longest there is an expectation that any new specialist will go online and they do. Saying its not working is not an honest argument. Some places are ahead of others but it does work - despite the issues with compliance. It could work a lot better if there was a focus on compliance with standards. The problem is not the lack of SMD but ignorance and denial of reality. The doom and gloom generated by the PCEHR also doesn't help. Its an expensive side show that distracts people from the main game, which is working point to point messaging using existing standards.

With the greatest respect and I do have respect for you and for Medical Objects,your own practice (the world headquarters of Medical Objects) is hardly a typical practice, though with numbers like that you probably do lift the national average.

The figures make it plain, Australia is failing to give community health providers eHealth tools. I presented to graphs some people in Canberra recently. There were long silences and no disagreements, I was asked to send more graphs.

I don't think it'd be useful for me to go into my views on the PCEHR right here but I think it is really important for the Australian health sector to be aware that automating the interactions between primary care and the rest of the health system is very important and very valuable and an opportunity that it is foregoing.

My practice contributes 0.5% of the Sunshine coast traffic, so we are just like 90+% of the other specialists on the Coast. The tools we use are available for all users and we do look after all sectors of the health landscape. Similar results are seen in other areas we have had established for a while.

We are about giving all users the tools they need to enable connectivity in a standards based manner. What we would like is endpoints that can reliably handle standards compliant messages and generate reliable displays of more than PIT so we can ramp it up more quickly and improve display quality.

What we need from Canberra is a pinch of governance and less attempts to implement, as they are not very efficient at implementation, something that is true the world over.

I would agree that handouts to a handful of vendors is the wrong approach. Give the money to the users, but implement some requirements for software/message compliance would be a much more efficient approach. The software will become more expensive as there needs to be a much bigger spend on software quality, but compensating the users allows a level playing field for quality software.

Good receiver compliance would also make SMD interoperability between messaging vendors safe to switch on, currently it is not.